Health policy and planning最新文献

Gender-based violence (GBV) is a major public health issue, further intensified in humanitarian crises. In Ethiopia's northern conflict (2021-ongoing), the scale of GBV underscores the urgent need for context-sensitive policy and service delivery. We conducted a policy analysis of national GBV-related policies within the context of the northern Ethiopia conflict. This was complemented by 9 focus group discussions with relevant stakeholders, i.e., community representatives and 10 key informant interviews with key policymakers at sub-national and national levels. Data were analyzed thematically using the Health Policy Triangle framework. No reviewed policies were contextualized for humanitarian emergencies or inclusive of all GBV forms. Most focused exclusively on sexual violence against women, overlooking other GBV types and male survivors. Policy development was largely top-down, involving government bodies and international actors, with minimal input from frontline providers or affected communities. There was also a lack of consensus on which policies are implemented, driven by poor dissemination, resource constraints, limited prevalence data, and weak coordination. Ethiopia lacks a government-led, humanitarian-specific GBV policy. This hinders a coordinated health response. Strengthening community participation in policy formulation, ensuring inclusive and context-relevant policy content, improving coordination among all governmental and non governmental GBV actors, and addressing funding gaps are critical for effective GBV response in humanitarian settings.

Current approaches to health system resilience tend to prioritize system-level outcomes (e.g. functionality) while overlooking key underlying social processes, contexts, and power-laden interactions through which resilience is produced. When community resilience is subsumed under health system resilience, without attending to distinct contextual factors, it can lead to fragmented approaches or maladaptive outcomes that misalign with the resilience of communities. Therefore, resilience approaches need to include additional methods that incorporate analyses of power structures and context. We propose intersectionality theory as a methodological lens to investigate the underlying social processes and power dynamics that shape community resilience and health system resilience interactions. An intersectionality approach prompts researchers to distinguish how resilience capacity is derived through the involvement of community actors, their unique intersecting social identities, and their lived experiences. Including an intersectional lens in resilience approaches provides researchers with the tools to identify points of practical constraints that arise at the intersection of communities and health systems, with particular attention on the burdens that are placed on community actors.

Measurement of contact coverage of maternal and newborn health services may overestimate the benefits of the care that is provided, because the quality of care is not captured. It is therefore important to better understand the opportunities and challenges of capturing elements of care quality in routine health information systems (RHIS). This study explored healthcare workers' (HCWs), health sector managers' and policymakers' perspectives on the value and limits of routine health data to understand the quality of maternal and neonatal health services in Tanzania. We conducted qualitative research during two periods to capture perspectives across facility, district, regional and national levels. In Mtwara region in 2023, we conducted ethnographic observations at two hospital labour wards and 29 in-depth interviews with healthcare workers, hospital leaders, and district/regional managers. In 2025, we carried out 17 additional interviews with regional managers in Mtwara and with key national-level stakeholders. Our findings demonstrate that Tanzania's RHIS provides a valuable but partial picture of quality of care for maternal and neonatal health services. Care processes - including both provision and experience of care - are captured only to a limited extent. Using boundary object theory, we highlight how the same health information must serve diverse stakeholder needs. While there are opportunities to integrate more quality-of-care indicators, standardized RHIS cannot be expected to comprehensively capture the multifaceted nature of care quality. For quality measurement to support meaningful local health service improvement, a flexible, bottom-up approach is essential. However, the current emphasis on top-down oversight acts as a barrier for local-level data use. Measurement of the quality of facility-based care which is relevant and feasible requires a fundamental shift in current RHIS priorities - from systems that extract data for those 'up there' to platforms that also create value for those who provide care.

Continuum of care in maternal and child health (MCH) services is a key strategy for improving MCH outcomes. This study examines the effect of conditional cash incentives and community health worker support on the uptake of the continuum of MCH care, defined as the sequential utilization of antenatal, skilled delivery, and postnatal services. Using nationally representative cross-sectional datasets and a difference-in-difference framework, we find that both interventions significantly improved the continuum of MCH care. The intent-to-treat estimates showed a 5-percentage-point increase in the proportion of women completing the full continuum of care. Heterogeneity analysis revealed more substantial effects among educated women, those in urban areas, and those in higher wealth quintiles. Insights from qualitative interviews with mothers and community health workers suggested that awareness of antenatal care and institutional delivery increased; however, postnatal care was typically sought only in response to complications, and the uptake of all recommended MCH services as a full continuum was often hindered by intersecting demand- and supply-side barriers. Notably, participants emphasized that sustained community health worker engagement had a more significant impact on ensuring care continuity than cash incentives alone. These findings highlight the need for policy strategies that enhance community health worker-led support mechanisms, combined with financial incentives, to promote the comprehensive and sustained use of maternal health services among disadvantaged population groups.

India's AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) integration policy emphasises medical pluralism. However, implementation occurs within a complex health system where the state apparatus, through its governance and policy processes, affects health services and outcomes. This study explores how state and policy complexities shape AYUSH integration processes and practitioners' capacities in primary healthcare. Qualitative research was conducted in an eastern Indian state and involved observations (19 days) and interviews (37) with AYUSH doctors, biomedical doctors, nurses, pharmacists, and administrators. Thematic analysis enabled identification of themes. State-level employment rules placed AYUSH doctors on low-paid, short-term rolling contracts, but the effects of this marginalised position were intensified by irregular AYUSH medicine supplies and shared governance between two Directorates. Governance of integrative facilities and AYUSH medicine stock-outs shifted practice patterns toward biomedical treatments by AYUSH doctors to keep health services functioning, which increased biomedicine demand and further narrowed the scope of AYUSH in a self-reinforcing cycle. Inter-departmental collaboration between the Directorates was fragmented, lacking accountability and prioritisation of AYUSH integration activities. Limitations in AYUSH medicines and the absence of promotional campaigns narrowed the scope of AYUSH services and facilitated the "biomedicalisation" of AYUSH integration. Local governance bodies offered occasional support, but their involvement was neither formalised nor consistent. Thus, integration processes emerged not from linear policy structures but from feedback mechanisms in which changes in policy priorities at the state and district levels produced disproportionate effects on AYUSH integration, demonstrating a system responsive to resource and information flows. Achieving medical pluralism will require adaptive governance: setting iterative integration targets, establishing cross-directorate collaboration and learning platforms, and increasing the resource independence of AYUSH.

Managing hypertension is particularly challenging in high-altitude regions of China due to chronic hypoxia and limited healthcare access. Continuity of care has been proposed as a cost-effective approach, yet its economic impact in this context remains unclear. Using basic medical insurance claims data from 11,823 hypertensive patients in three high-altitude cities (January 2022-December 2023), this study examined the association between continuity of care and medical expenditures. A generalized linear model with a log link function was employed to analyze total medical costs, while a Tobit regression model was used to assess out-of-pocket (OOP) costs. Heterogeneity was analyzed based on sex, insurance type, and ethnic groups. If the Bice-Boxerman Continuity of Care Index (COC) were maximized, hypertensive patients could experience a 15.63% reduction in total medical costs and 25.92% in OOP costs. If the Usual Provider of Care Index (UPC) were maximized, total medical costs and OOP costs could decrease by 18.94% and 31.61%, respectively. Heterogeneity analysis indicated that both COC and UPC were negatively associated with OOP costs across sex and insurance types, but significant associations with total medical costs were mainly observed among Tibetan patients, females, and those enrolled in Urban and Rural Resident Basic Medical Insurance. Higher continuity of care was significantly associated with lower medical expenditures for hypertensive patients residing in high-altitude areas; however, the magnitude of this beneficial effect varied considerably across different population subgroups. These heterogeneous effects suggest that interventions designed to enhance care continuity may need to be tailored to specific patient demographics. Therefore, future prospective studies or policy interventions are warranted to validate these findings.

Bottom-up theory demonstrates that networks of actors play important roles in policy implementation, yet limited attention has so far been paid to the influence that actor networks might have on the implementation of PHC strategies and outcomes. This study examined the roles actor networks play in the implementation of Community-based Health Planning and Services (CHPS) in Ghana, focusing on the nature and patterns of relations and structure and strength of prevailing collaborations. This was a cross-sectional study using a social network analysis methodology in eight districts across two regions in Ghana. The study population was implementers of CHPS from the community, district, regional and national and development partners. Data were obtained using a modified pre-tested closed-ended social network questionnaire. To establish collaborative relationships, knowledge of other actors and the degree of communication on issues related to CHPS implementation were surveyed. Data were analysed using Gephi software version 0.9.2. The analysis demonstrated existing actor networks of Community Health Committees (CHCs), Community Health Officers (CHOs), Community Health Volunteers (CHVs), Sub-district, and district-level networks, including local government actors and political leaders, as well as regional, national, and development partner actors in CHPS implementation. The nature of relations showed isolated networks of CHCs, CHVs, and sub-districts across both regions. Patterns of interactions revealed that CHO networks collaborate with each other, while CHCs primarily collaborate with CHOs. Overall, weak collaborative relationships were noted among the actor networks (network density < 10%). The results suggest segmented, decentralized networks with limited involvement of critical actors, including community-level, local government, political leaders, national-level and development partners in CHPS implementation. The network analysis highlights weak collaborative relationships among actor networks in CHPS implementation, a practice which negatively impacts its implementation experience. The study highlights pathway to strengthen cohesion and improve collaborative relationships in addressing CHPS as a PHC strategy.

The systematic involvement of community health workers (CHWs) in hypertension management can improve outcomes and achieve blood pressure control. However, much of this evidence is from effectiveness trials conducted under ideal conditions, with little evidence from programmes operating in routine conditions. In Kenya, recent policy changes have expanded CHW roles to routinely incorporate non-communicable disease (including hypertension) service delivery. We undertook an exploratory descriptive qualitative study in one county, examining what CHWs now referred to as Community Health Promoters (CHPs) do in relation to hypertension service delivery, influences on their involvement and considerations for sustainability. We found ad hoc and fragmented CHP involvement in practice despite policy guidance for community-level hypertension service delivery. Drawing on the extended health systems building blocks framework, we identified multiple capacities that can support expanded CHPs roles in hypertension care including the pre-existing community health service structure and societal partnerships, as well as their level of motivation. Policy provisions for CHP professionalisation (payment of stipends, provision of CHP kits with varied commodities and training) create an enabling environment. However, sustained adoption of the new CHP roles may be impeded by i) challenges in meeting the financial and supply chain obligations for stipend payments and commodities respectively; and ii) inadequate sensitisation of communities and frontline-providers concerning expanded CHP roles and implications for facility-level hypertension care. To effectively implement recent policies, strengthening coordination and communication across all community and health system actors is needed, as well as clarity and deliberation on long-term financing for the community health system.

The community care sector is a major component of social protection systems in South Africa. However, despite considerable investment and policy attention on social protection in South Africa, the community care sector continues to face enormous challenges and pressures. On the one hand, government invests a significant amount on social spending, and aims to honour its constitutional responsibilities towards improving the health and social welfare of the country. On the other hand, community-based care workers are socially and economically marginalised, and community care services remain fragmented and often inaccessible to those who need them most. This paper explores how elements of South African policy on the community care sector emerged historically out of policy responses to parallel social crises of HIV/AIDS and unemployment in the period 2000-2010. We draw on the theories of John Kingdon (agenda setting) and Nancy Fraser (needs interpretation) as the lenses to analyse data from policy documents, published literature and key informant interviews. We show the convergence and consolidation of policies across sectors in the study period into a community care sector characterised by competing and unresolved tensions: between constitutional promises of social and economic rights and enduring conceptualisations of social reproductive labour as feminised, devalued and 'invisibilised' within the private, domestic sphere. This results in a community care sector that has limited effectiveness as an arm of the social protection system, and which continues to be plagued by the structural inequalities that characterise South African society.

Elective caesarean sections (c-sections) present a significant public health challenge due to associated health risks and increased costs. This study examines the causal impacts of a unique natural experiment in São Paulo, Brazil: Law 17,137/2019, which temporarily allowed pregnant women to opt for c-sections in public healthcare facilities. Using a difference-in-differences estimator, we analyse the Law's effects on c-section rates across various hospital types, municipal characteristics, and demographics. The Law led to a significant and immediate 3.03 percentage point increase in c-section rates in public hospitals. Notably, this effect was limited to the public sector, with no consistent changes observed in private or mixed facilities. The impact was also temporary; following the Law's revocation less than a year later, c-section rates promptly reverted to pre-enactment levels, indicating no lasting effects. We find no evidence that the Law shifted deliveries from paid private care to free public hospitals. Our analysis reveals heterogeneous impacts, with the largest increases in c-section rates occurring in municipalities that had lower baseline c-section rates, a greater reliance on public healthcare, and fewer healthcare resources. These findings suggest that the law disproportionately affected areas with greater public health system strain. Interestingly, the increase in c-sections primarily occurred among low-risk births and had no detectable effect on newborn health outcomes, such as birth weight or Apgar scores. The additional 4,500 c-sections performed under the law created an added fiscal burden of approximately R$459,000 for the public health system, based on the cost difference between vaginal and c-section deliveries. This study underscores that while granting elective choice may seem empowering, it can lead to a surge in unnecessary, costly, and riskier procedures, highlighting the crucial need to consider both equity and resource implications when designing healthcare policies.